Transcript for audio podcast: Access to Medicaid Managed Care

[Meridith Seife] I'm Meridith Seife, the Deputy Regional Inspector General for the Office of Evaluation and Inspections in New York. With me today is Vince Greiber. We're here to talk about two new reports on Access to Care within Medicaid Managed Care. Vince, tell us a bit of what you found.

[Vince Greiber] We found that people enrolled in Medicaid managed care organizations may not be getting access to the care they need when they need it.

[Meridith Seife] But isn't managed care an increasingly popular option for state Medicaid programs? And isn't Medicaid enrollment growing under the Affordable Care Act?

[Vince Greiber] Yes on both counts. Over the last decade, managed care has grown rapidly, and today almost three-quarters of all Medicaid enrollees are served by such plans. Experts also predict that over the next three years, an additional 18 million Americans will be enrolled in Medicaid - most of them in managed care plans. We did these two studies to see if enrollees in these plans were having problems getting access to care and what the States, and CMS, can do to address those problems.

[Meridith Seife] So this will obviously impact a lot of people. How did you check to see if access to care was a problem?

[Vince Greiber] As a part of our research, we called to schedule appointments with a sample of 1,800 providers from around the country.

[Meridith Seife] What was the result of those calls?

[Vince Greiber] Unfortunately, what we found was troubling: Fifty-one percent of the providers we called could not offer an appointment to new patients. In a number of cases, providers told our callers that they never heard of the specific doctor listed in the managed care plan, or that the provider had retired or left the practice years ago.

[Meridith Seife] But 69 million Americans currently rely on Medicaid for their health care, and soon, Medicaid will cover an additional 18 million people. Isn't it important to ensure all those beneficiaries have access to a wide array of doctors to provide necessary care? How are States doing that?

[Vince Greiber] States try to ensure that patients have access to health care by creating minimum standards for all Medicaid managed care plans. But these standards vary widely from State to State.

[Meridith Seife] Can you give us an example?

[Vince Greiber] Yeah, for example, one State requires managed care organization to have one primary care provider in place for every one hundred enrollees, while another State only requires one provider for every twenty-five hundred enrollees. And sometimes, there were no standards governing access to certain kinds of providers like specialists. These variations mean that people living in one state may not have the same level of access to care as people in another state.

[Meridith Seife] You note that the standards vary, but, how effectively are States enforcing the standards that they create?

[Vince Greiber] We found that also varies significantly with some states doing a better job than others. The one thing in common was that most states failed to find even a single violation of their access standards over the five year period we studied.

[Meridith Seife] Well, isn't that a good thing if states aren't finding violations?

[Vince Greiber] Not necessarily. It might mean that states are not finding violations because they are not looking. It turns out that states that did not find violations were states that relied on plans to self-report that they were in compliance. On the other hand, States that did find violations did their own testing, like making the same kind of "secret shopper" calls we made.

[Meridith Seife] What did you find among the providers who were able to offer care?

[Vince Greiber] While most providers who offered care could see patients within two weeks, some patients had to wait as much as a month or more to be seen. In fact, 10 percent of patients had to wait longer than two months to get the care they needed.

[Meridith Seife] So does the OIG believe that States are actually meeting their access standards?

[Vince Greiber] When providers listed as participating in a plan cannot offer appointments, it creates a significant obstacle for enrollees seeking care. It also suggests that the actual size of the provider networks may be considerably smaller than what is presented by the managed care plans. So our work does raise questions about whether patients are getting treatment where and when they need it.

[Meridith Seife] Very interesting. So what are you recommending to the Centers for Medicare and Medicaid services, or CMS?

[Vince Greiber] We made a number of recommendations to improve CMS and State oversight. Specifically, we recommended that CMS strengthen its oversight of State standards. We also recommended that CMS improve its methods for evaluating how well States comply with standards. Finally, we recommended that CMS work with States to improve the accuracy of plan information and make sure that plans only include participating providers. CMS agreed with each of our recommendations.

[Meridith Seife] Vince, thank you so much for sharing this important work. And we look forward to seeing how States and CMS respond to these recommendations.